
WHAT THE STATE SHALL 

DO IN THE 
CARE AND SUPERVISION 
. OF SCHOOL CHILDREN 



AN ADDRESS PRESENTED AT 
THE FOURTH INTERNATIONAL 
CONGRESS ON SCHOOL HY- 
GIENE AT BUFFALO, N. Y., 
AUGUST 25, 1913, BY 



Eugene H. Porter, M.A.,M.D..Dr.p.H. 

State Commissioner of Haalth , 



ISSUED BY THE 

NEW YORK STATE DEPARTMENT OF HEALTH 

DIVISION OF PUBLICITY AND EDUCATION 

ALBANY, N. Y, 






WHAT THE STATE SHALL DO IN THE CARE AND 
SUPERVISION OF SCHOOL CHILDREN 

The importance of this field of health work has long since been 
admitted by those familiar with the problems presented by the 
recent developments in sanitary science. We are fully persuaded 
that the best index of community health is the physical welfare of 
the school children in that community. So far there is agreement, 
but when we begin to consider methods of procedure, differences 
of opinion appear. It would seem very probable that any diversity 
of view regarding plans to be adopted for the proper care and 
supervision of school children would arise either from a lack of 
a comprehensive and firm grasp of the question or a failure to 
clearly discern just what definite results are to be accomplished. 
It ought to be very clear to everyone that if we efifectively guard the 
physical well being of our school children, teach them the funda- 
mental laws of health and train them in the observance of these 
laws, that we have gone a very great ways indeed not only in pro- 
tecting the health of the individual but in establishing and confirm- 
ing the health of communities and indeed of the State. Such an 
advance as that in health work would be one of the great founda- 
tion stones upon which might be successfully erected that ideal 
structure of public health protection which would actively and 
visibly promote and determine State and National efficiency and 
happiness. 

But if we are to supervise and care for our school children we 
must not only know what kind of care we are to give and what 
kind of supervision we are to exercise, but we must know some- 
thing definitely and accurately about the school children themselves. 
There is only one way in which we can find out anything about 
the children in our schools, and that is to examine them, and this 
examination must be made by those who have had some training 
in the work, who understand the vital points at issue, and are com- 
petent to bring out the facts that such an examination is searching 



for. Many examinations of school children have been held and the 
results of such examinations have been duly recorded on thousands 
and thousands of cards and buried in as many forgotten reports. 
It is not the examinations that do any good, nor the tabulated results 
that are of any value, but the use of these reports and their in- 
terpretation, and the intelligent work based upon them. The proper 
care and supervision of school children is preventive medicine in 
the highest sense of the term, and preventive medicine is the best 
and cheapest health insurance that a community can take out. 

Some time ago was begun the formation of hygienic committees 
for universities. These committees have employed an admirable 
scheme of investigation, have adopted wise measures for bettering 
the hygienic conditions of buildings and the health of the students. 
Such matters as ventilation, humidity, water, sweeping, toilets, 
gymnasiums, lodging-house inspection, medical adviser, emer- 
gency cases, health education are given full consideration, together 
with the various other subjects which have to do with the health and 
habits of life of students. Admirable as this scheme is and import- 
ant as it is as an example of what can and should be done, yet 
its greatest value lies in the illustration given of the value and 
power of such close and critical examination of the surroundings 
and physical condition of the students concerned. Of necessity 
it reaches but an infinitesimal part of those attending the schools 
and colleges in the Union. But what can be done for college 
students should be done for every school child in the United States. 

It is a curious fact, and by no means gratifying to our national 
pride, that when we wish to strongly illustrate the value of modern 
sanitary methods we draw our most striking illustrations from our 
island and provincial possessions. Modern sanitary science, for 
example, has abolished yellow fever in Cuba, discovered the cause 
and largely controlled the ravages of hookworm anemia in Porto 
Rico, barred yellow fever and Chagres fever from the Canal Zone, 
and isolated leprosy in Hawaii and the Philippines. This work 
has practically revolutionized conditions in our tropical possessions 
and enabled the President to say that in the short twelve years 
we have been responsible for our people in the Tropics, we have 
made more progress in the discovery of methods of prevention and 
cure of tropical diseases than all other countries have made in the 
past two centuries. This advance has been due to modern 
sanitary methods backed up by intelligent and authoritative ad- 
ministration. And the results show what intelligence and authority 



can do when joined together. We have indeed intelHgence in 
modern sanitary methods in these our United States, but it is not 
always backed by authority, and we have in the same place author- 
ity that is notably lacking in intelligence. 

Typhoid, pneumonia, tuberculosis, the black plague of venereal 
infection, are still ravaging the land. If they were tropical diseases 
how horrified we should be at their ravages and what active measures 
should we take to control and extirpate them. And yet I think it 
may be safely said that modern sanitation if permitted, if we could 
unite authority and intelligence in health matters as they should be 
united, could effect as marvelous changes here as it has in the Canal 
Zone or in Havana. 

Herbert Spencer said a long time ago that to be a good animal 
is the first requisite to success in life, and to be a nation of good 
animals is the first condition of national prosperity. 

It is true that we protect our cattle. The great State of New 
York, with nearly ten millions of people, spends many times more 
in looking after the health of the cattle of the State than it does 
for the health of its citizens. In 1909, the Health Department had 
$146,980, which was less than one-half of one per cent, of the total 
expense of the State Government. At the same time there was spent 
for the protection of game, fish and forests, $568,595.80. 

We are all familiar with the wastes of life in our country going 
on day by 'day and year by year. Some of us know that much of 
this sickness and death is absolutely preventable. We are aware 
that we do not need to know more just now regarding the prevention 
of disease, but we do need to apply the knowledge that we have 
immediately and without further delay. The attitude of the people 
is easily understandable. It is as Governor Hughes said a short 
time ago, " only because we are accustomed to this waste of life 
and are prone to think of it as one of the dispensations of Prov- 
idence, that we go about our business little thinking of the pre- 
ventive measures that are possible." 

The hog is fortunate in being an animal of commerce. If it were 
not, the waste of hog life would doubtless exceed that of human life. 
We are a generous people. After every disaster money flows in 
to relieve distress. A great epidemic occurs — towns, cities, states 
and even the Nation contribute liberally for the relief of the dis- 
tressed community. If it is right and proper for the State 
and the Nation to appropriate money for the relief of distress, it is 
certainly right and proper to contribute money for the prevention 
of distress, which means in most cases the prevention of disease. 



Our system of philaiuhropy is essentially false. It has developed 
naturally and in its early growth, animated by noble motives, susr 
taincd by high ideals, it did a great and beneficent work. But in- 
creasing knowledge has shown the futility of much of the mis- 
directed philanthropy of to-day. If a child is threatened with 
illiteracy, millions are forthcoming for its education, but the child 
that is threatened with preventable disease is told that just now 
nothing can be done ; wait until disease has attacked you and you are 
helpless. Then there is a hospital provided for you and you will 
be taken there and an attempt will be made to save your life. There 
are hospitals endowed for this very purpose. 

And there you have the matter in a nut-shell. It is not the curing 
of disease that is important ; it is the prevention of disease. Where 
one life may be saved by appropriate treatment, a thousand lives 
may be saved by timely preventive measures. 

The problems of health have to do principally with environment 
— home, street, school, business. And it is because this is so that 
it is worth trying to relate health instruction to industry and govern- 
ment, to preach health from the standpoint of industrial and 
national efficiency rather than of individual well-being. So that 
while the State cares for the child and undertakes his examination 
and his general health supervision, the real and important thing, the 
great result to be attained, is not so much the health and efficiency 
of the one child as it is the resulting increased efficiency in the com- 
munity itself. The supervision and care of the school child, his 
instruction in hygiene, necessarily brings in all the persons in his 
home, takes in the groups made up of friends and acquaintances, 
reaches out and eventually embraces the entire community, and 
so lifts up and elevates the standards of living. 

We must find some working program that will bring all these 
members of the groups mentioned, together, and make it easy for 
them to observe health standards, and we must remember that there 
is a great gap between health laws and health law enforcement. 
We are constantly making the mistake of concentrating our atten- 
tion upon the morals and pretensions of candidates and officials 
instead of judging government by what government does. It makes 
no particular difference just how our officials are exercising author- 
ity, but it makes a tremendous difference when what they do 
makes men freer in the enjoyment of health and earning power. 
In protecting health as in reforming government, as Allen says, 
" an ounce of efficient achievement is worth infinitely more than a 
moral explosion." 



Undoubtedly some legislation will be necessary if we are to make 
the progress we desire in the care of the physical welfare of our 
school children. Such legislation should be as brief, as simple, and 
as fitted to the place and the time and the people as possible. And it 
must be remembered that the value and permanence of the results 
that are sought for in any reform movement or in any type of 
governmental action, depend largely upon the adaptability of the 
movement undertaken and of the principles on which it is based 
and the special conditions of the time. If we wish, therefore, to 
improve the welfare of our schools we must study carefully the 
conditions of the State at this particular time and see to it that 
our movement in advance is adapted to these conditions. 

An instructive illustration of the great advance made in another 
field is shown by a proposed Children's Code of the State of New 
York, compiled by Justice Deuel of the Court of Special Sessions 
of the City of New York. He proposes to attain, among other 
things, the following four purposes : 

1 Indubitable protection of the child against all suggestion of 

crime, hence the elimination of all objectionable references 
to him in the Penal Law and the Criminal Code, and the 
specific definition of juvenile delinquency. 

2 Extension of the children's court, without any increased ex- 

pense, to every city, town and hamlet in the State, at the 
same time giving to each the home rule privilege of develop- 
ing and utilizing to the utmost the resources of the court. 

3 The institution of uniform procedure and the acquisition of 

uniform statistical data throughout the State. 

4 The legal employment of scientific agencies in the detection of 

mental or physical causes of waywardness which, uncor- 
rected, predisposingly lead to crime; and a procedure like- 
wise legal, compelling curative treatment. 

I cite these provisions of this proposed code simply to show 
what progress the legal profession has made in dealing with what 
may be called the criminal or perhaps the moral side of the child's 
nature. Such a code as that proposed by Justice Deuel would have 
been impossible in this State ten years ago and unthinkable twenty- 
five years ago. It will be noted that the underlying purpose of the 
judge is evidently the prevention of crime rather than the punish- 
ment of crime. 

In a paper so limited as this, it is only possible to give a brief 
outline as to what should be the duty of the State in its care of 



the school child. I have already said that the best index to com- 
munity health is the physical welfare of its school children. If 
we can fix upon the test to be applied at school of home conditions 
affecting both the child's health and his progress at school, it will 
be possible in the name of the school to correct those conditions 
if necessary, just as it will be easy to read the index, because the 
child is under study control for the greater part of the year 
from six to fourteen. This test should be the physical record of the 
child obtained by the examination and re-examination for the 
physical signs called for by the record card. This card, among other 
things, should register the weight, height, age and other measure- 
ments. It should take note of the nutrition, of enlarged glands, 
of cardiac or pulmonary diseases, of defective spine, chest or ex- 
tremities, of defective vision or hearing, of the condition of the 
teeth, of the palate, of the tonsils, of post-nasal growths, of de- 
ficient and defective nasal breathing, and of the mentality. 

When such a card as this is filled out for every child in a 
class, in a school or city, the story told points directly to the physical 
health rights neglected. In the examination of school children in 
New York city running from March, 1905, to January, 1908, 
275,641 children were examined and 198,139, or 71.9 per cent., 
were found to be defective. If this percentage should obtain 
throughout the whole of the United States then the army of children 
would be 7 out of 10, or over 14,000,000. These figures have been 
vigorously attacked by those who do not believe that such a per- 
centage of the children in our public schools have any serious de- 
fects. But it is really not material whether these figures are exact 
or not. If they over-state the truth or under-state the truth, the 
health authorities of the country should find out. 

This record of physical examination is the only way in 
which the existence in a community of conditions prejudicial to 
health that particularly affect the child, can be discovered. The card 
record will show whether the child sleeps in a dark, ill-ventilated 
and crowded room, if he has too little to eat or the wrong things 
to eat, and whether he has eye trouble or adenoids or enlarged 
tonsils; whether he has defective lung capacity, which may mean 
improper breathing, or too little exercise or too little food. Let me 
say again that it is the use of information and not the measuring 
of information that improves the health. The mere examination 
of school children does little good. The examination tells what 
child should have special attention, what parents need to be warned 



against as to the condition of the child, and what home conditions 
need to be corrected. 

Let us keep clearly in mind the distinction between medical school 
inspection and medical school examination. Medical inspection is 
simply the search for communicable diseases ; medical examination 
is the search for physical defects, many of .which furnish the soil 
for contagion. Among the important defects which demand correc- 
tion, if the health and efficiency of the child are to be protected and 
his value as a future citizen of the commonwealth is to be preserved, 
are mouth breathing, diseased glands, which means adenoids and 
enlarged tonsils, ear troubles, eye strain, malnutrition, diseases of 
the teeth, and contagious diseases. 

It will be impossible in a brief paper of this character to discuss 
separately each of these defects, to attempt to point out their serious- 
ness, their frequently fatal results and the great importance of their 
correction. Those who have given this subject any considerable 
attention know full well that these conditions should be no longer 
neglected, but should be promptly, energetically and wisely cor- 
rected. 

For a working program for the supervision and care of school 
children, that suggested by Mr. Allen will serve at least as an ex- 
cellent basis for discussion and future action. 

First. A thorough physical examination of all candidates for 
teachers' positions. 

Second. A thorough physical examination of every single child 
in every single school upon entering, and periodically during the 
school life. 

Third. Supervision by physicians of hygienic practices in school- 
rooms and upon playgrounds. 

Fourth. Restriction of study hours at school and at home to 
limits compatible with health. 

Fifth. Establishment of follow-up plan to ensure action by 
parents to correct physical defects and to attend to physical needs. 

Sixth. The teaching of hygiene so that children will cultivate 
habits of health and see clearly the relation of health and vitality 
to personal happiness and the future efficiency. 

Seventh. Central supervision of school hygiene. 

Eighth. Information gained at school regarding conditions prej- 
udicial to community health should be published and made the basis 
of an aggressive campaign for the enforcement of sanitary laws. 

This is by no means all that Mr. Allen suggested, or that has 
been suggested by others, but it will serve excellently as an outline 



8 

to guide our ad\ance in the betterment of conditions in our schools. 
I am thoroughly con\'inced that this work should be in the hands 
of the health authorities, and that all medical examinations of school 
children should be made by competent physicians. 

This work of school inspection and examination gives us a clear 
view of some of tlie most important defects in the community health, 
and when to this picture is added that given by a sanitary survey of 
the same community, town or city, made by competent inspectors, 
which would take in the question of water supply, sewage disposal, 
tenement conditions, clean streets, etc., we have a pretty definite 
and accurate picture of the essential health conditions existent. 
With such sources of information the annual report of the Board 
of Health should give as clear a picture of the community's 
health for any past week or past quarter, as an accountant's books 
would give of the condition of any commercial business. Further- 
more, such a Board of Health should not only keep track of one 
community alone, but this community should be compared with 
other communities of similar size and each community compared 
with itself year by year. Such comparisons as these have not often 
been made and I do not know of a State where such records exist. 

I believe thoroughly that it is the duty of health authorities 
to compel all citizens under their jurisdiction to cultivate habits 
of health, and to punish all who persistently refuse to acquire those 
habits so far as the evils of neglect are in any sense a danger and 
a menace to the community. And one of the unlimited educational 
possibilities of health boards consists in their privilege to point out 
repeatedly and cumulatively the industrial and community benefits 
which result from habits of health, and the industrial and com- 
munity losses which result from habits of unhealthy living. And 
should it be thought that this health program encroaches upon indi- 
vidual liberty we may recall what one of the greatest and modern 
biologists has recently said : "As we march onward toward the true 
goal of existence, mankind will lose much of its liberty, but in return 
will gain a high measure of solidarity. The more exact and precise 
a science becomes, the less freedom we have to neglect its lessons." 
These new duties are before us and it is only by organized, en- 
lightened and persistent effort that we may hope to accomplish our 
ends. 

I thoroughly appreciate the fact that what I am proposing is more 
or less ideal, and yet I am as thoroughly convinced that within a 
few short years it will be realized that the plan proposed is absolutely 



practical and sane. A public official said a little while ago : " I am 
fully aware of how little I am doing and how little at best I shall 
have done when my time is up. Corrections and improvements in 
government, as in all things, may not be done at once, but only 
patiently and gradually and, may I say, charitably; explaining and 
teaching as you go, even as Isaiah says : ' Precept upon precept, 
line upon line ; here a little and there a little.' " 

I think we may wish that these words — modest, patient and 
charitable — could be hung above the desk of every ranting, de- 
nouncing reformer who labors to make the people believe that he 
holds the remedy for the complete and sudden reform of every exist- 
ing abuse, health or otherwise. 

Realizing then the limitations of human power, the existence of 
honest differences of opinion, the dependence of all true and lasting 
education and reform on the people themselves, let us march steadily 
onward and let us remember that the truest measure of civilization 
and of intelligence in the government of a State, is the support of 
its institutions of science and of health. For the science of our 
time in its truest sense, is not the opinion or prejudice, the strength 
or weakness of its votaries, it is the sum of our knowledge of nature 
with its infinite applications to State welfare, to State health, to 
State progress, and to the distribution of human happiness. 



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